Marie, a 16-year-old soon to be sophomore in high school, was enjoying her summer vacation. She had worked most of the summer and was looking forward to being a camp counselor the last two weeks before vacation came to an end. She came to the office to have a rash checked out.
She was ending a lively conversation on her cell phone when I walked in the examining room. "Gotta go," she said. "I'm at the doctor's office. I'll call you right back." Her mom put down the magazine and said, "Thank you so much for seeing Marie on such short notice. She is suppose to leave for camp on Sunday and we're concerned about this awful rash on her chest. Since she's going to be a counselor for young kids I wonder if it is contagious and maybe she shouldn't go."
In taking Marie's history I learned that the rash started five days ago on the left side of her chest, just lateral to the breast bone. There never was a fever, nor did she ever feel sick or ill. At first she thought it might have been an insect bite or sting because it tingled and itched slightly. After the first day it had grown to the size of a quarter. The skin was red and somewhat uncomfortable. By the second day it had almost doubled in size and started to form multiple small "vesicles" or blisters that were grouped in clusters. Subsequent days it ceased spreading and the vesicles began to crust. The involved area was not painful per se, but at times it was itchy and other times it would ache. She showed the area to her mother the morning of the visit, whereupon the appointment was immediately made.
After examining the young lady I found her completely normal with the exception of the rash on her chest. The vesicles or blisters had begun to crust over and I did not see what appeared to be new ones forming. It was of interest that the rash was over the left side of her chest where the heart would be, and stopped abruptly at the middle of her breast bone. In other words, it went directly to the midline but did NOT cross it.
Marie energetically asked, "Well, can I go to camp?" I told her that I didn't see any reason why not. She had shingles, which is a reactivation of the chicken pox virus. This is a relatively benign and self-limiting disease that will totally resolve with one-to-two weeks. Marie was thrilled, but her mom looked skeptical.
"There's just one problem, doctor," she said in a doubting voice. "Marie has never had chicken pox. She had the vaccine. How could this be shingles?" She went on to say how happy she had been that Marie could get the vaccine when she was little so that she would never have to go through a case of chicken pox.
This was an excellent and valid question. In general, when one gets a case of chicken pox the vesicular rash will come in waves or crop up to 7-to-10 days, after which they crust, scab and then disappear. From beginning to end a case of chicken pox will last approximately 10-to-14 days. In a short period of time one cannot even tell that a patient had chicken pox.
What is unique to the virus that causes the disease is that the virus had the capability of resting dormant in the nerve root, deep within the body. In some individuals, for some unexplained reason, the virus may be reactivated which causes a patch or cluster of vesicles like those seen in Marie's case. This is shingles. The cluster of vesicles seen with shingles follows the distribution of that particular nerve along the skin. It usually follows a swipe or stripe distribution, and rarely crosses the midline.
While shingles typically present in someone who has had chicken pox in the past, it can also occur in people who have had the vaccine but never had the disease. One study reported the incidence of shingles after a case of natural occurring chicken pox in healthy patients under the age of 20 years was 68 per 100,000. The reported incidence of shingles in healthy under 20 year olds who successfully received the varicella vaccine was 2.8 per 100,000. While it is not as common, it certainly can occur.
I explained to Marie and her mother that shingles was self-limiting, which means that it will go away completely without any particular treatment. We usually treat the symptoms of pain or itching if it is truly warranted. The vesicles usually crust over in a few days.
As for being contagious, it is only spread by direct contact with the fluid of a weeping vesicle. Since the area involved in Marie's case is always covered by clothing, she doesn't have to worry about being contagious. Furthermore, she was far enough into her shingles that they had almost all crusted over, thus making them no longer contagious. An interesting fact about this disease, however, is that if a person who has never had chicken pox or the vaccine comes into direct contact with the weepy fluid of a shingles lesion, they can get active chicken pox.
This is in stark contrast with chicken pox which is highly contagious through the respiratory tract. By merely coughing or sneezing, a person with chicken pox can spread the virus throughout an entire room, and potentially infect anyone who does not have antibodies or protection against the virus.
Marie was now thrilled that she was going to be able to go to camp. Mom was please as well. But this gold moment was short lived as Marie opened her cell phone to call her boyfriend. "Couldn't you at least wait until we get in the car?" mom pleaded in vain.